Retainer medicine and medical students

Earlier this month, Dr. Bob Centor posted one in a long line of posts explaining the appeal and merits of retainer medicine, especially in the outpatient general medicine context. Retainer practices free both physicians and patients from the constraints of third-party payment systems, putting the patient firmly in control and allowing for the development of resilient physician-patient relationships that are more difficult to establish when visit length is otherwise effectively limited to 15 minutes (though these days I keep seeing “10 minutes” bandied about; is this a sign?).

What is fundamentally subversive about retainer practice, however, is that it represents a renunciation of dependence on government (or private insurers). So many primary care physicians in academia and the community still feel that the best way to “save” primary care is to run crying into Congress’s arms, to beg for even more money, and thus to enhance the dependence on Congressional whim that currently characterizes any practice that is largely dependent on Medicare or Medicaid.

As you might imagine, this wresting of autonomy tends to get some interest groups riled up.

But let’s look at retail clinics! Capitalizing on patient discontent with the current primary care model, these clinics have been expanding at a rapid clip, and are apparently doing a pretty good job of providing medical care. This may well be a desirable innovation in the provision of medical services, but that discussion is beyond the scope of this post. Perhaps what’s most surprising: many of them require patients to pay out of pocket without the possibility of insurane reimbursement. And patients do! Patients want to!

What this tells us is really what we knew already: primary care in the US is not working for patients. We knew that it’s not working for physicians either. It’s hard to see how stay-the-course pleading for government largesse is expected to work “this time, really!”

It’s interesting to think about these debates on how best to save primary care while reflecting on recent conversations with other first-year students. Somehow, through the crush of almost 200 now-forgotten introductions repeated over the course of the week, I managed to strike up a few conversations on preliminary specialty choice. Lots of students here, myself included, believe strongly in the importance and the role of primary care medicine. We just don’t want any part of it in the current system. What’s more, most of the classmates I asked weren’t entirely familiar with the concept of retainer practice, and it’s doubtful that we’ll be exposed to many role models who function in such a practice.

And that’s a shame. Orientation was full of lofty verbiage about role models and mentors. What better way is there to reinvigorate medical student interest in primary care than to expose them to role models who have chosen a practice structure that minimizes the hassles, overhead, and constraints of third-party payment, and instead is focused on what drew all of us to medical school in the first place: working for the patient?

While it’s too early to talk meaningfully about a specialty decision (though you’re more than welcome to start a betting pool…) it’s not too early for me to say this: the only way I would seriously consider paediatrics, general internal medicine, or family practice residency in the US is if the retainer model of practice is still viable when it comes time to decide (i.e. hasn’t been banned by law or marginalized by organized medicine).

Of course, I’m fortunate to have Canada as a relatively easy alternate option. And here’s the kicker. The phrase “lifestyle specialties” in the US usually refers to the “ROAD to happiness:” radiology; ophthalmology; anaesthesiology; and dermatology. [Medical students are big on the mnemonic acronyms] In Canada? Well, according to my own physician… it’s family practice.

I have seen no serious suggestions that retainer medicine be banned. Many journals regularly feature articles on it and publish how to guides on getting started. It is a model well suited to primary care.

It’s true that there isn’t a serious movement to ban it yet. However, demonization of retainer practices as “greedy doctors catering to the rich” emanate from otherwise respectable think tanks and professional societies. What’s more, some states (NJ and MA come to mind) have, in the past year, semi-seriously toyed with the idea of forcing physicians to take insurance (usu. just Medicaid) as a condition of licensure.

It’s a remote possibility, especially at this point early on in my training, but it’s a real one nonetheless.